Column - Adding millions to Medicaid system isn't the solution

Statement

"We can't simply put more people into a broken system that doesn't work."

Those words weren't uttered by a Republican foe of the Affordable Care Act, although they certainly have been echoed over time. Rather, they were spoken by President Obama himself in 2009, as he conceded the point that dumping millions onto Medicaid or Medicare was no real solution to health care reform.

Yet, just four years later, here we are.

As the media focuses on whether states will sign onto Medicaid expansion as part of the ACA, we need to take some time and consider the much more important question of whether Medicaid expansion is the right solution for the uninsured in the first place.

Unfortunately, there was never a robust national discussion about the wisdom of expanding Medicaid to fill coverage gaps. No one ever asked: If we were to redesign Medicaid to fit today's needs and long-term fiscal challenges, would it look the same?

We doubt it. Instead, a program created in 1965 for a narrow population was assumed to be the best means to provide coverage to all low-income Americans.

From 1990 to 2010, national Medicaid expenditures have risen from $73.7 billion to more than $401 billion, a 445 percent increase. Over the same period, the Medicaid caseload increased 135 percent, from 22.8 million people to 53.6 million.

Medicaid is a vital program, funded jointly by federal and state governments. Because of past expansions, it is expected to serve wide and diverse populations. But it tends to treat each individual effectively the same, regardless of the wide range of differences they may require in terms of care.

It's also important to consider that Medicaid is continuously on the nonpartisan Government Accountability Office's "high risk list" due to its high susceptibility to fraud. The GAO cited $21.9 billion in improper payments in 2011 alone.

Many argue that federal funding is too good to pass up. We argue that it's too good to be true.

The Texas Health and Human Services Commission projects Medicaid expansion will cost tens of billions in combined state and federal funds over the next 10 years. Again, that's just the cost of expansion, not the program as a whole.

Over the same period, full implementation of the ACA -- both Medicaid expansion and other provisions -- would cost Texas more than $18 billion in general revenue.

That's simply unsustainable, and we remind everyone that during a time when all the talk in Washington is about sequestration that no federal "promises" can be believed on face value. It's quite possible that states will find themselves alone to fund this vastly expanded program. When that happens and the money just isn't there, very real, and very difficult actions will be required.

Our country is $16.5 trillion in debt, and national Medicaid expenditures through 2023 are projected to be $8.41 trillion. With that sort of price tag, states -- even those like ours that reject the expansion -- will be under continued fiscal pressure, and that will only further risk access to care.

Instead of acknowledging these issues to start a discussion, the U.S. Department of Health and Human Services seems comfortable ignoring them. Texas doesn't have such a luxury.

States must have the flexibility to tailor their programs in a way that best serves the needs of their citizens. We must also explore bold, new solutions. This might be the only way to guarantee access for patients for services they will continue to need.

We need to take a long, hard look at a range of different solutions if we are to address these fundamental issues and discuss the benefits and drawbacks of each.

Possible options could be: a greater role of health savings accounts, cost-sharing plans, block grant funding, per capita caps, ensuring better coordination of the programs that serve the disabled, and how the long-term care services many seniors rely on later in life are delivered, to name just a few.

Instead of encouraging states to be the "laboratories of invention," the Affordable Care Act again projects a narrow vision from Washington, discouraging the rethinking of care delivery.

We must rebuild this bridge of trust, but it must begin with the recognition from this administration that our concerns are valid. No one cares more about the health of Texans than Texans.

Rick Perry is governor of Texas. Michael C. Burgess is a doctor and Texas congressman.